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Vacation Consent Form

Thank you for selecting Village Veterinary Hospital.

We welcome the opportunity to provide the best care possible for your pet. Please help us meet your needs better by taking a moment to complete this information sheet

Information and Travel Details

Pet Owner's Name *

First

Last

Pet Owner's Email *

Pet Owner's Phone *

Please provide a phone number at which you can be reached while traveling.

Pet Owner's Secondary Phone

Please provide a phone number at which you can be reached while traveling.

Location at which you can be reached while traveling

Date of Departure

attending you medical

Date of Return

Vacation Consent and Authorization

I hereby authorize the people listed in this form as authorized caretakers, able to present my pet(s) for treatment in my absence should an injury or illness occur to my pet(s) that requires veterinary care. This includes any medical treatments, anesthesia consents, or surgical procedures, and to sign for charges.

I will provide the authorized caretaker(s) listed below with a method of payment in the form of cash, check (personal or bank), credit card (Visa, Master Card, or American Express), or Care Credit) in order to pay the bill at the time of service. If providing a credit card, I will provide the card number, type of card, and expiration date.

I authorize any veterinarian to provide my pet with veterinary care and essential medical service.

I authorize charges for my pet's care *

Not to exceed a specific amount
At whatever amount necessary

Do you consent to any veterinarian providing your pet with intensive medical care and essential medical service? *

I do
I do not

In the event that the attending veterinarian determines that your pet is suffering and/or is incurably injured, do you give your consent for euthanasia? *

I do
I do not

Understand, IF the health is this critical, we will try everything in our power to get in contact with you before any decisions are made.

Authorized Caretaker Information

Please add additional roles for multiple caretakers.

Name *

Email *

Phone *

Signature *

Clear Signature

Signature of Owner *

Clear Signature

Signature Date *

Vacation Consent Form

Thank you for selecting Village Veterinary Hospital.

Information and Travel Details

Vacation Consent and Authorization

Authorized Caretaker Information

Compassionate Veterinary Care in Bellingham and Beyond

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